Cost-Effectiveness of Salt Substitute and Salt Supply Restriction in Eldercare Facilities

Key Points Question Is it cost-effective to replace regular salt with salt substitute and to restrict salt supply to kitchens in eldercare residential facilities? Findings In this cluster randomized clinical trial of 1612 older adults residing in eldercare facilities, the salt substitution intervention showed considerable potential to be cost-saving, whereas the salt restriction strategy did not show significant results. The salt substitution cost savings were estimated to be large if the intervention were rolled out to all eldercare facilities in China. Meaning These findings may support government planning and implementation of public health programs to replace regular salt with salt substitute in eldercare facilities in China and other countries.

eFgure 1. Flow Chart vs vs Analysis * Reasons for not participating the baseline survey: 185 (49.2%) were on temporary leave (mostly for treatment of their illne ss at hospitals or personal business such as travel to the relatives), 33(8.8%) were handicapped persons (with deaf, mute, blindness, dementia, etc.), 59(15.7%)were with severely ill or bedridden, 32(8.5%)refused baseline survey, and 67 (17.8%) with unknown reasons.# the facility dropped due to administration reason.& the facility dropped due to manager incompliance.reported in 2020 US dollars, $1 = 6.90 yuan.Daily cost of anti-hypertension medication was calculated based on the procurement price of anti-hypertension drugs, with a mean of $0.137027.In the absence of uncertainty ranges for the costs, the standard deviation was assumed to be 12.5% of the base value to allow for probabilistic sensitivity analysis.† Between-group comparisons were done using two-sample Wilcoxon rank-sum (Mann-Whitney) test.-1185.99 (-3058.88, -36.82)QALYs, quality-adjusted life years; CI, confidence interval.* The difference in utility was derived from a linear mixed model with adjustment for baseline value and clustering effect at facility level.The SD of QALY values was large because we considered the discounted lifetime QALY loss of cardiovascular deaths in the calculation of QALY change.In probabilistic sensitivity analyses, the plausibility range was assumed to be ±2 5% of the base value.* In 2022, there were a total of 43,410 civil service facilities providing 5,452 thousand beds in China.The vast majority of these were eldercare facilities, numbering 40,587 with 5,183 housand beds.The remaining included mental health service facilities, child welfare and protection agencies, etc. Collectively, these facilities accommodated a total of 2,299 thousand individuals.Therefore, in this study, we assumed that the number of cared elderly individuals amounted to 2,119 thousand (2,229*5,183/5,452).

eTable 6. Health Indicators for Study Participants at Different Stages of Intervention
48 residential eldercare facilities enrolled from 4 regions, with 2248 residents • Age < 55 years old (n=260) • Not participated in baseline survey due to temporary leave or other reasons* (n=376) Recruitment 48 residential eldercare facilities, with 1612 eligible participants•

Comparisons in Baseline Characteristics Between Participants Analyzed and Not Analyzed for the Assessment of Effect on Blood Pressure Among 1612 Eligible Participants
*p value was obtained from models to compare baseline characteristics between participants assigned with restricted supply ver sus usual supply among analysed and not analysed, accounting for clustering at facility level.#p value was obtained from models to compare baseline characteristics between participants analysed and not analysed, accounting for clustering at facility level.
*p value was obtained from models to compare baseline characteristics between participants assigned with salt substitute versus regular salt among analysed and not analysed, accounting for clustering at facility level.*eTable 4.

Estimated MACE Treatment Cost for Each Participant at Different Stages of Intervention
Costs are reported in 2020 US dollars, $1 = 6.90 yuan.Cost per episode in 2020 was extracted from China Health Statistical Yearbook 2021, with a mean cost of stroke espisode being $1606.14, mean cost of acute myocardial infarction espisode being $4403.09,and mean cost of congestive heart failure espisode being $1300.58.In the absence of uncertainty ranges for the costs, the standard deviation was assumed to be 12.5% of the base value to allow for probabilistic sensitivity analysis. *

eFigure 2. Probabilistic Sensitivity Analysis of the Restricted Supply Intervention at 2 Years Using Monte Carlo Simulation The
red line denotes the willingness to pay threshold, which is $10435 per QALY gained.